WORKING WITH OLDER PEOPLE - Professional guidance - NMBI

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WORKING WITH OLDER PEOPLE - Professional guidance - NMBI
Nursing and Midwifery Board of Ireland (NMBI)

WORKING WITH
OLDER PEOPLE
Professional guidance

1    Working With Older People
Nursing and Midwifery Board of Ireland (NMBI)

This professional guidance was originally published in April 2009 as Professional Guidance for Nurses
Working with Older People (First Edition).

This document was re-issued in November 2015 for the relaunch of the NMBI website. This involved
reviewing the content, updating dated NMBI references and redesigning the document. However, the
professional guidance itself reflects what is in the 2009 edition.

About NMBI

The Nursing and Midwifery Board of Ireland (NMBI) is the independent, statutory organisation which
regulates the nursing and midwifery professions in Ireland. For more information about our role and
functions, visit www.NMBI.ie/What-We-Do

Glossary

A full glossary of all the terms used in this and other NMBI publications is published on our website on
www.NMBI.ie/Standards-Guidance/Glossary
Nursing and Midwifery Board of Ireland (NMBI)

CONTENTS

Contents                                                                    3

Introduction                                                                4

Context For Professional Guidance                                           6

     Demographics of Ageing 	                                               6
     Range of settings for care 	                                           6

Guiding Principles And Beliefs For Nursing Care Of The Older Person         8

Standard For Nurses Working With Older People                             10

Standards Of Nursing Practice                                             11

     Standard 1: Person-Centred Holistic Care 	                            11
     Standard 2: Therapeutic Relationship 	                                11
     Standard 3: Care Environment 	                                        12
     Standard 4: End Of Life Care 	                                        13

Standards Of Nursing Quality                                              14

     Standard 5: Quality Of Care 	                                         14
     Standard 6: Professional Development 	                                15

Compentencies For Nurses In The Care Of The Older Person                  16

     Domain 1- Professional/Ethical Practice 	                            17
     Domain 2- Holistic Approaches To Care And Integration Of Knowledge 	 18
     Domain 3: Interpersonal Relationships 	                              20
     Domain 4: Organisation And Management Of Care 	                      22
     Domain 5: Personal And Professional Development 	                    23

Appendices                                                                24

     Appendix 1. Local Policies And Guidelines 	                           24
     Appendix 2. Elder Abuse 	                                             25
     Appendix 3. Nursing Assessment 	                                      26

References                                                                28
Nursing and Midwifery Board of Ireland (NMBI)

INTRODUCTION

Registered nurses care for older people in all healthcare settings including hospitals, long-term care
facilities and in the community. As our ageing population grows, along with increase life expectancy,
nurses will have to provide care for increasing numbers of older people.

This demographic change will present many new challenges to the multi-professional team and reinforces

“
the need for registered nurses in all care settings to continuously develop and support this area of
nursing.

             The guidance standards have been
             developed for nurses who work with older
             people in all healthcare settings. They

                                                                                                  ”
             are also intended as a source of information
             for the older person and his/her family.

The importance of registered nurses to focus on the older person’s needs pervades every part of the
health care system. For example, the nurse in the acute hospital must be alert to preventing functional
losses, as this can have considerable impact on an older person’s health and self-care status. Likewise, the
nurse in a continuing care unit must be knowledgeable about acute care problems despite the institution’s
focus on rehabilitation or continuing care. This demands that all registered nurses must be are fully aware
of the needs of new technically-focused functions, while sustaining and nurturing fundamental skills.

Nursing is central to the delivery of high quality care for older people. This requires all registered nurses,
both generalist and specialist, in all healthcare settings to develop knowledge of age-related issues and
illnesses.

4       Working With Older People
Nursing and Midwifery Board of Ireland (NMBI)

The objectives of the Guidance Standards are to:
• Define the standard of nursing care that can be expected by all older people, their family and informal
  carers who are in receipt of nursing care in the various settings and roles in which the nurse practices

• Provide professional guidance and direction for nurses caring for older people across all healthcare
  settings in order to facilitate safe, competent and ethical nursing practice

• Provide a nursing framework for end of life care that embraces living and dying as part of the normal
  care structure and processes in all care settings

• Provide guidance to assist the nurse in decision-making and self-assessment as part of reflective
  practice

• Provide guidance to the nurse in determining what knowledge and skills are required to provide quality
  care

• Promote ongoing practice development

• Form the basis for the development of local protocols and policies specific to the various contexts of
  practice (Appendix 1)

• Promote continuous quality improvement through regular monitoring and evaluation.

5      Working With Older People
Nursing and Midwifery Board of Ireland (NMBI)

CONTEXT FOR PROFESSIONAL GUIDANCE

Demographics of Ageing
The majority of developed countries have accepted the chronological age of 65 years as a definition of
the older person (WHO 2009). But chronological age may differ considerably from a person’s functional
age, and age-related changes occur at different rates for different people. The number of older people
in society is increasing internationally. Over 11 % (467,926 people) of the Irish population are 65 years or
older. As in other EU countries, the proportion of older people is increasing to a predicted level of 15% in
Ireland in 2021(CSO 2007). People aged over 80 years as a proportion of persons aged 65 years and over
has been rising steadily and is now 24.1% (CSO 2007). By 2030, one in four Irish people will be 65 years or
older. The greatest increase will be in the over 80 year olds. Estimates suggest that older people with an
intellectual disability will increase by over 20% by 2021 (McConkey et al 2006).

Over the past decades, there has been a steady increase in life expectancy, mainly due to improvements
in sanitation and infectious disease control through vaccinations and antibiotics. Now, the older generation
is growing older because of developments in the treatment of chronic diseases, cardiovascular and
neurologic disease, as well as cancer. But the losses brought about by an age related disease give rise
to increasing levels of disability in later life (O’Neill 2006) and may pose a real threat to maintaining
independence and well-being. The proportion of people living with a disability increases with age from
18.7% in the 65 – 69 age group to 58.6% in the 85 and over age group (CSO 2007). The presence of
any chronic medical condition and/or degenerative joint disease, hearing and visual impairments and
dementias all result in the increased risk of complications and functional decline, which are associated with
an increased burden on the older person, their families and carers (DoHC 2008) and increased health care
utilisation in all care settings.

Seventy-five per cent of people aged 65 years and over live independent and active lives within their
community; 5.5% live in long term residential care (CSO 2007) and the remainder are cared for in the
community and in other healthcare facilities. A more integrated and person-centred service response
could enhance older people’s independence, dignity and choice (NESF 2005). Older people are a
diverse group who possess a broad range of abilities and needs. This, along with the varied lifestyles,
environmental conditions, and life histories characteristic of older people, creates the need for highly
individualistic nursing care (McConnell 1997). Cognisance must also be taken of older people whose
first language is not English and/or those from ethnic minority groups, whose numbers in the future will
increase and whose needs may also include language difficulties and cultural diversities.

Range of settings for care
Older people are, and will continue to be, the major users of health and social care (Garavan et al
2001). They are cared for in every setting: acute hospitals, private and public long-term care facilities and
in the community. Nurses are increasingly caring for older people in acute general services, rehabilitation
services, mental health services and intellectual disability services. Long-term care refers to a continuum of
services addressing the health, personal care and social service needs for persons who require help with
activities of daily living. In the past number of years, there has been a trend away from the custodial model
of care.

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Nursing and Midwifery Board of Ireland (NMBI)

Living at home is the preferred choice of many older people (Ruddle et al 1997) and of national and EU
policymakers(DoHC 2006; HSE 2006; European Commission 2007). Nurses can help them achieve this
by supporting their independence through empowerment, developing flexible responses to their needs
and supporting their carers, who are often older people themselves. However, long term residential care
continues to play an important role in the continuum of care services for older people. Older people
who have a disability, who are frail or ill or who are unable to live at home because of a lack of formal or
informal carers, will continue to need long-term residential care (NCAOP 2000). Five and half percent of
people over the age of 65 years are resident in long-term residential care facilities in Ireland (CSO 2007)
and are among the most vulnerable in our society by reason of their multifaceted complex needs, special
supports and the continuing care assistance they need (Age and Opportunity 2003; O’Connor et al 1986).
Institutional continuing care of the older person may be provided in a number of settings: Health Service
Executive (HSE) publicly-owned and financed institutions, i.e., welfare homes, continuing care units/
hospitals and community nursing units, or in privately-owned and voluntary nursing homes.

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Nursing and Midwifery Board of Ireland (NMBI)

GUIDING PRINCIPLES AND BELIEFS FOR
NURSING CARE OF THE OLDER PERSON

The core beliefs of person, environment, health and nursing were identified as being of the greatest
importance to nursing (Fawcett 1984). These beliefs, together with the Code of Professional Conduct and
Ethics for Registered Nurses and Registered Midwives (NMBI 2014) and identified factors which facilitate
quality care of the older person (Murphy 2007), provide the basis for a framework for the nursing care of
the older person in all care settings.

Person
The nurse who cares for the older person supports the belief that:

• Each older person is of worth and value

• The older person possesses a broad range of abilities and needs

• Each older person has unique physical, psychological, social and spiritual needs

• The older person and his/her family/representative are the unit of care

• The older person and family have the right to make informed decisions about all aspects of their care
  and the nurse respects the level of participation desired by the older person and/or family.

Environment
The nurse who cares for the older person supports the belief that:

• A flexible, caring environment is established wherever the older person is cared for, whether in the acute
  hospital, private or public continuing care facility or in the community

• Care of the older person refers to a continuum of care that addresses the physical, psychological, social,
  and spiritual needs of the older person

• Care is best provided through collaboration and teamwork

• The older person is protected from all forms of abuse (physical, psychological, social, sexual, financial,
  violation of person’s rights, neglect).

Health
The nurse who cares for the older person supports the belief that:

• Health includes physical, psychological, social, cultural, developmental, environmental and spiritual

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Nursing and Midwifery Board of Ireland (NMBI)

    well-being

• Quality of life involves assisting the older person achieve their optimum state of health and well-being

• Each older person and/or family, if appropriate, define their quality of life

• Health for a number of older people is a relative and dynamic process due to their multifaceted complex
  needs, special supports and the continuing care assistance they require.

Nursing the Older Person
The nurse who cares for the older person supports the belief that:

• Fundamental to nursing practice is the relationship which is based on trust, understanding, compassion
  and support and serves to empower the older person to make informed choices

• Care is provided in a non-ageist and non-discriminatory manner that is sensitive to the older person and
  their family

• The goal of each nurse-patient interaction is to establish the conditions that promote healthy living;
  compensate for disease-related losses and impairments; prevent further disease-related losses;
  promote comfort and facilitate the diagnosis, palliation and treatment of disease

• Nursing practice involves advocating for and with the older person and/or family to maintain their
  quality of life and, at the end of their lives, to experience a peaceful and dignified death

• Nursing practice is person-centred and is based on best available evidence

• Nursing care respects the privacy, dignity and integrity of the older person and family

• The central role that families/friends play in the life of the older person is acknowledged and actively
  supported

• The ethical principles of autonomy, beneficence, non-maleficence, justice, fairness, truth-telling and
  confidentiality are all integrated into the provision of nursing care

• There is a need to commit to actively participate in updating and maintaining knowledge through
  continuous professional development and ongoing education programmes.

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Nursing and Midwifery Board of Ireland (NMBI)

STANDARD FOR NURSES WORKING WITH
OLDER PEOPLE

Standards are developed to guide evidence-based nursing practice for older people. They provide a
framework and outline the essential elements and competencies required by nurses who care for older
people in all healthcare settings. They are designed and are intended to complement other national
standards and guidelines including the National Quality Standards for Residential Care Settings for Older
People in Ireland (HIQA 2007).

The moral principles (NMBI 2014) underpinning the guidance standards for care of the older person
include:

•    The right to quality nursing care
•    Respect for the dignity of the older person
•    The principle of beneficence
•    The principle of autonomy and control
•    Justice
•    Truth

The standards are generic in nature and aim to capture the diverse settings and roles in which the nurse
practices. While factors unique to particular care environments will impact on a nurse’s practice,
the standards ultimately reflect the expected levels of performance. Each standard is accompanied by a
supporting rationale. Competencies for the standards are supported by indicators. The indicators are not
intended to be complete or all-inclusive but should be interpreted in the context of the specific practice
setting of the individual nurse and may be further developed to address specific contexts of practice and
required competencies. Competence is a complex multidimensional phenomenon. It is defined as the
attainment and application of knowledge, intellectual capacities, practice skills, integrity and professional
and ethical values required for safe, accountable, compassionate and effective practice as a registered
nurse.

The standards are clustered around the two themes of nursing practice and nursing quality.

                 Standards of Nursing                                              1
                                                                                  Person-centred

                                                     6
                 Practice (1-4)
                                                                                   holistic care

                 Standards of Nursing

                                                                                                   2
                                                     Professional
                 Quality (5-6)                       development

                                                                                                   Therapeutic
                                                                                                   relationship
                                                                 Professional Guidance for

                                                   5
                                                                   Nurses Working with
                                                                       Older People

                                                                                              3
                                                    Quality of
                                                     caring
                                                                                                  Care

                                                                          4
                                                                                              environment

                                                                           End of life
10        Working With Older People                                          care
Nursing and Midwifery Board of Ireland (NMBI)

STANDARDS OF NURSING PRACTICE

These standards describe nursing activities, including those that are demonstrated using a nursing
framework.

Standard 1: Person-Centred Holistic Care
Comprehensive person-centred nursing care is provided within the organising framework of
assessment, identification of needs, planning, implementation and evaluation

Rationale:

Older people are a diverse group who possess a broad range of life stories, experiences and abilities
and have complex and multifaceted needs. They are affected in unique ways by the combined effects
of the ageing process, the disease process and the environment, which challenge their sense of self and
influence their perception of their quality of life.

Alleviating vulnerabilities experienced by the older person is the central organising perspective of
person-centred care (Hobbs 2009). Vulnerabilities include both compromised physiological states and
threats to a person’s identity. Therefore, wherever the older person is cared for, whether in hospital,
community setting or continuing care facility, comprehensive person-centred nursing care is required which
is provided by the nurse who is knowledgeable, skilled, vigilant, proactive and is positively motivated
about caring for the older person (McCormack et al 2006). Person-centred care is ‘knowing’ the person,
their values, and who the person is (Murphy 2007; McCormack 2006). It includes care aimed at preventing
untoward events and negative experiences for the older person. Knowing the person enables the nurse
to see behind the ‘mask’ of ageing, illness or disability (Clarke 2003). As well as providing ongoing
support and education to the family in their caring role, person-centred care is about offering choice, and
encouraging and empowering the older person in all decisions of care.

The organising framework through which the nurse delivers care involves assessing, identification of
needs, planning, implementing and evaluating nursing care. This framework is the foundation of clinical
decision-making and encompasses all significant actions taken by the nurse in providing nursing care.

Standard 2: Therapeutic Relationship
A therapeutic relationship is developed with the older person that maximises the older person’s
self-esteem and quality of life

Rationale:

Providing a suitable psychological and social care environment assists the older person to maintain
dignity, integrity and achieve his/her potential. Relationship-centred care is central to this (Nolan
et al 2006).

It is important to know the older person and to understand his/her viewpoint (Berglund and Ericsson
2003). This demands skills in verbal and non-verbal communication, listening and presence. Even if their
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Nursing and Midwifery Board of Ireland (NMBI)

capacity for understanding language is severely impaired, the non-verbal behaviour that accompanies
being asked for an opinion and seeking permission will do much to convey to older people that they are
valued.

As well as being an effective communicator, the nurse needs to have an appreciation and knowledge of
the barriers and difficulties in communicating by the older person due to culture, intellectual disability,
or a change in physical, sensory or cognitive status, and employ strategies to help overcome these
difficulties. Behaviour that challenges may be an attempt to communicate based on need and/or can be
an indicator of, for example, medical illness, including delirium, mental health problems or organic brain
disease.

Vulnerability, anxiety, loneliness and alienation increase when the familiar touchstones of the older person’s
identity are missing, for example, when they are out of their own environment.

Achieving quality of life for the older person is contingent upon knowledgeable and competent
person-centred holistic care (Murphy 2007), which is delivered in a way that embodies compassion, respect
for dignity and an appreciation of the whole person and family.

Standard 3: Care Environment
A therapeutic safe care environment is promoted and maintained which supports dignity, respect,
privacy and independence for the older person

Rationale:

Older people can be profoundly affected by their environment, which can be as large as a community,
a neighbourhood or a hospital or as small as a ward, a home, an individual room or a bed space area.
The concept of environment is an essential element in the nursing care of the older person and the aim
should be to provide an ‘enriched’ environment wherever the older person is cared for (Nolan 2006).
As well as impacting positively or negatively on the person’s sense of health and wellbeing (Weiss
and Lonnquist 2000), the environment also conveys messages of caring and belonging. A change in
environment can mean moving from an older person’s own residence to another residence or institution,
or moving from the person’s own bed space or room/unit to another within an institution.

Care settings with familiar and home-like physical environments can ease psychological stress and
positively affect health outcomes for the older person (Murphy 2007b).

Regimentation and institutionalisation contribute to loss of control by the older person and must be
guarded against. Institutionalisation has been compared to a syndrome. It portrays certain rules and
rituals that occur on a daily basis. Activities of the day are fixed, with one activity being tightly secured
by the next. The nurse can counter this through collaborating with the older person regarding their care
environment, including the patterning of their day, thereby ensuring choice, dignity and respect.

Environment also impacts on the performance of tasks by the older person, from the simple to the
complex. A sense of control is fundamental to wellbeing. Though people with delirium and dementia may
require extra assistance, they have the right to dignity and respect.

Care environment and social dimensions of care are central to the older person’s quality of life. The ideal
residential facility is a place where ‘people live their lives with as little physical or psychosocial discomfort
as possible … with dignity and a good quality of life’ (Sander and Walden 1985).

12      Working With Older People
Nursing and Midwifery Board of Ireland (NMBI)

Standard 4: End Of Life Care
The older person receives comprehensive, compassionate end of life care that is person-centred and
responds to the older person’s unique needs and respect for his/her wishes.

Rationale:

Many older people have an advanced, progressive, life-limiting illness whose condition deteriorates over
an extended period of time with a long lead time to death (O’Shea et al 2008). Adopting a palliative
approach to care throughout the older person’s illness trajectory enables staff to move away from viewing
palliative care as restricted to care of the dying person only (Phillips et al 2008). End of life care is a vital
and integral part of all clinical practice, whatever the illness or its stage, informed by a knowledge and
practice of palliative care principles (DohC 2001; O’Shea et al 2008).

When older people are at the end of their lives, nurses can make a difference to them and their families by
creating and facilitating a therapeutic milieu that addresses their physical, psychological, social,
cultural and spiritual needs. This includes collaboration with other healthcare professionals in providing
evidence-based/best practice and establishing mechanisms for consultation regarding practice and
referral. Older people may feel disempowered in their decision-making at this time. In order to protect
their rights, it is important to be guided by, and work within, a legal framework (Keys 2008).

Providing relief from distress will facilitate a comfortable death, and one that is remembered with peace
and comfort by family and friends.

13      Working With Older People
Nursing and Midwifery Board of Ireland (NMBI)

STANDARDS OF NURSING QUALITY

These standards describe nursing quality in caring for older people, including activities related to
performance appraisal, education, use of theory and ethics.

Standard 5: Quality Of Care
The nurse caring for the older person evaluates and enhances the quality and effectiveness of his/
her nursing care and practice

Rationale:

The older person requires comprehensive, evidence-based, person centred nursing care which focuses on
enhancing their quality of life.

Quality of life is a complex and multidimensional concept. Its meaning changes over time and is perceived
differently in different contexts and care settings. When measuring quality of life, health, physical function,
social and psychological factors should be included (O’Shea et al 2008), from both a subjective and
objective point of view (Davies and Higginson 2004; Corner and Bond 2004). Therefore, every person
experiences a unique quality of life (Haas 1999).

Six factors that facilitate quality care of the older person in continuing care settings in Ireland have been
identified along with three factors that hinder such care (Murphy 2007). The six facilitating factors are:

1.   Promoting independence and autonomy
2.   A home like environment
3.   Person centred holistic care
4.   Knowledgeable skilled staff
5.   Knowing the person
6.   Multidisciplinary resources.

The factors that hinder quality nursing care being delivered are:

1.   Lack of time and/or restrictions on patient choice and involvement (with an emphasis on the physical
     aspects of care)
2.   Resistance to change
3.   Being bound by routine, which includes a focus on task allocation. Routinised care is an important
     hindering factor to providing quality care.

Quality of care for the older person is an integral part of healthcare provision and quality issues are of
importance to the provision of excellent nursing care (Kitson 1997).

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Nursing and Midwifery Board of Ireland (NMBI)

Standard 6: Professional Development
The nurse acquires and maintains current knowledge to improve the quality of life and nursing care
of the older person

Rationale

Care of the older person is a rewarding and dynamic area of nursing.

The challenge for nurses caring for the older person is to embrace evidence-based practice as it evolves,
while sustaining and nurturing core fundamental skills and values (NCNM 2007). The growing body of
knowledge, and the intensity of quality of care required to meet the older person’s complex needs,
reinforces the need for nurses in all settings to commit to, and engage in, reflective practice, continuing
professional development and education programmes (NCMN 2003) on an ongoing basis and increase
their scope of practice.

Acknowledging the central role that families and friends play in the lives of the older person, the goal of
each nurse-patient interaction is to assist older people live to the maximum of their ability; cope with their
physical, psychological, social, sensory, cognitive or spiritual deficits and losses; prevent further
disease-related losses; and promote and maintain comfort and dignity through healthy living and
the dying phase. This demands that the nurse builds a relationship with the person, and has a sound
knowledge base, together with a wide variety of skills, on which to develop clinical expertise and
implement best-practice guidelines.

Outcomes of care improve when older people are cared for by nurses with demonstrated competence in
older person nursing and in environments that structure nursing care around the needs of the older person
(O’Neill 2006; Harrington et al 2001).

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Nursing and Midwifery Board of Ireland (NMBI)

COMPENTENCIES FOR NURSES IN THE CARE
OF THE OLDER PERSON

Competencies are supported by indicators. The indicators are not intended to be complete or all- inclusive
but should be interpreted in the context of the specific practice setting of the individual nurse and may be
further developed to address specific contexts of practice and required competencies.

                                                      1
                                                Professional/ethical
                                                     practice

                       5
                      Personal and
                                                                               2
                                                                           Holistic approaches
                      professional                                             to care and
                      development               Domains of                  the integration of
                                                                               knowledge
                                                Competence

                                     4
                                   Organisation and
                                                                       3
                                                                   Interpersonal
                                    management                      relationships
                                       of care

16     Working With Older People
Nursing and Midwifery Board of Ireland (NMBI)

Domain 1- Professional/Ethical Practice

                 Performance Criteria             Indicators

     1.1         Practices within a framework     èèPractices within the legislation, professional regulation and
                 of professional accountability     guidelines relevant to his/her scope of practice and care
                 and responsibility.                setting.
                                                  èèIntegrates accurate and comprehensive knowledge of ethical
                                                    principles and the Code of Professional Conduct and Ethics
                                                    for Registered Nurses and Registered Midwives within the
                                                    scope of professional practice in the delivery of nursing care
                                                    of the older person.
                                                  èèIntegrates knowledge of and respects and protects the rights,
                                                    beliefs and cultural practices of the older person.
                                                  èèAdvocates with and on behalf of the older person to protect
                                                    their rights.
                                                  èèSupports the right of the older person to lead an
                                                    independent life based on self-determination and choice,
                                                    ensuring adequate protection for those older people who
                                                    are unable to make their own decisions and/or protect
                                                    themselves, their mental and physical integrity and material
                                                    assets.
                                                  èèDemonstrates knowledge of, and implements,
                                                    the philosophies, policies, procedures, protocols and
                                                    guidelines of the healthcare institution.
                                                  èèResponds to, and reports, all incidences of elder abuse
                                                    (Appendix 2), incompetence, deviations from best practice,
                                                    and unethical and illegal practices.

     1.2         Practices within the limits of   èèDetermines own scope of practice using the Scope of
                 own competence and ensures         Nursing and Midwifery Practice Framework.
                 that he/she takes measures to    èèRecognises own abilities and level of professional
                 develop own competence.            competence.
                                                  èèCritically evaluates and bases practice on best available
                                                    evidence.
                                                  èèAccepts responsibility and accountability for consequences of
                                                    own actions or omissions in caring for the older person.
                                                  èèAssumes personal responsibility for maintaining current
                                                    knowledge to provide evidence-based, best practice nursing
                                                    care of the older person.
                                                  èèIdentifies a mechanism to support continuing professional
                                                    development to ensure continued competence.

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Nursing and Midwifery Board of Ireland (NMBI)

Domain 2- Holistic Approaches To Care And Integration Of Knowledge

                 Performance Criteria             Indicators

     2.1         Conducts a systematic holistic   èèPerforms a comprehensive assessment of the older person,
                 assessment of the older            which encompasses comprehensive history taking,
                 person’s needs, based on           physical examination and identification of health risk factors
                 nursing theory and                 (Appendix 3).
                 evidence-based practice.         èèInvolves the older person and their family as active partners
                                                    to identify needs, perspectives and expectations.
                                                  èèSelects and administers valid, reliable and age-appropriate
                                                    assessment and screening tools.
                                                  èèIntegrates and applies knowledge of age-related changes,
                                                    based on an understanding of physiological, cognitive,
                                                    psychological, social, and spiritual functioning.
                                                  èèAssesses family’s knowledge and skills, needs and level of
                                                    stress in providing care to the older person.

     2.2         Identifies the needs of the      èèUsing a nursing diagnosis classification system, critically
                 older person for nursing care.     interprets and utilises assessment data with clinical
                                                    decision-making skills to identify the older person’s goals,
                                                    needs and problems.
                                                  èèIdentifies potential and actual health issues and risks,
                                                    including stress, and their resultant consequences for the
                                                    older person/family.
                                                  èèCollaborates with older people in the identification of their
                                                    needs.
                                                  èèDocuments diagnosis in a way that facilitates the
                                                    determination of expected outcomes and the development
                                                    of a plan of care.

     2.3         Plans care with the              èèFormulates with the older person/family a plan of care based
                 older person and, where            on their needs and evidence-based practice.
                 appropriate, the family,         èèEnsures that the older person’s long-held routines and
                 taking into consideration          preferences are incorporated into the plan of care.
                 the therapeutic regimes          èèPlans adequate protection for those who are unable to make
                 of all members of the              their own decisions and/or protect themselves and their
                 interdisciplinary team.            integrity.
                                                  èèInvolves the older person as an active participant in the
                                                    decision-making process and plans care that is mutually
                                                    agreed.
                                                  èèDocuments plan of care in a clear, concise way, using
                                                    consistent terminology that is understood by all healthcare
                                                    staff.
                                                  èèEstablishes a process for discharge/transfer planning, if
                                                    appropriate, ensuring sufficient information and decision-
                                                    making time for the older person/family carer to allow smooth
                                                    transfer.
                                                  èèPlans for appropriate and timely consultation and/or referral
                                                    when the older person’s need or problem exceeds the nurse’s
                                                    scope of practice and expertise.

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Nursing and Midwifery Board of Ireland (NMBI)

              Performance Criteria           Indicators

     2.4      Implements planned nursing     èèProvides quality person-centred nursing care within his/her
              care and interventions to        scope of practice and as agreed with the older person/family
              achieve identified outcomes.     carer.
                                             èèCreates a safe and comfortable environment.
                                             èèFosters self-care and assists the older person to achieve the
                                               best quality of life as defined by the older person.
                                             èèFamiliarises the older person with the physical environment
                                               and activities and allows flexibility in the patterning of their
                                               day.
                                             èèMaintains the older person’s independence, dignity and
                                               sense of security by providing for example, familiar foods,
                                               drinks, routines, clothes, possessions, clear signage and ease
                                               of access to toileting and bathroom facilities.
                                             èèAdapts elements in the environment that immediately
                                               surround the older person and uses adaptive equipment to
                                               maintain the older person’s independence, control, dignity
                                               and privacy.
                                             èèAdheres to professional practice guidelines in the
                                               management and administration of all medications, including
                                               non-prescription/over-the-counter medications.
                                             èèEnsures the older person and or family carer are given
                                               sufficient time and information to make decisions.
                                             èèAnticipates, prevents or reduces risk factors that contribute to
                                               a decline in function and a reduction in quality of life.
                                             èèSupports and educates the family/informal carers in their
                                               caring and assist them to identify strategies for dealing with
                                               stress
                                             èèMaintains dignity, comfort and privacy for the older person
                                               throughout the end of life/dying process.
                                             èèFollows best practice national guidelines in caring for a
                                               person with cognitive or physical impairment, in consultation
                                               with the family.
                                             èèInitiates risk-reducing activities, while carefully considering
                                               the use of all restrictions/restraints (physical and chemical) in
                                               line with national guidelines.
                                             èèProvides support and protection and implements measures
                                               in accordance with national guidelines to protect the older
                                               person from incidences of elder abuse (Appendix 2).
                                             èèProvides support and protection for older people who
                                               experience difficulty in protecting themselves.
                                             èèIn consultation with the older person, provides a range of
                                               meaningful activities (group and individual) relevant to their
                                               interests, dependency level and appropriate to the care
                                               environment.
                                             èèCollaborates with other healthcare team members in
                                               providing best practice and establishes mechanisms for
                                               consultation regarding practice and referral.
                                             èèEnsures that a discharge summary accompanies the older
                                               person when/if they are being transferred from/to hospital,
                                               home or continuing care unit

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                 Performance Criteria            Indicators

     2.5         Evaluates progress toward       èèMonitors with the older person in relation to expected
                 expected outcomes and             outcomes.
                 reviews plans in accordance     èèContinually evaluates the effectiveness of nursing
                 with evaluation data and in       interventions and compares actual with anticipated outcomes.
                 consultation with the older     èèProvides an evidence-based rationale to modify and
                 person/family.                    individualise the care plan according to evaluation findings.
                                                 èèDocuments all elements of nursing care.

Domain 3: Interpersonal Relationships

                 Performance Criteria            Indicators

     3.1         Establishes and maintains       èèPromotes collaborative communication with the older person
                 caring therapeutic                and their carers.
                 interpersonal relationships     èèCreates and ensures a calm environment that is conducive to
                 with the older person/family.     communication, caring and ‘knowing the person’.
                                                 èèCommunicates meaningfully and sensitively supports the
                                                   older person in the expression of their feelings, fears and
                                                   expectations. Allows grieving for loss of roles, capacities and
                                                   relationships.
                                                 èèProvides emotional and social support to older person and
                                                   family.
                                                 èèEnsures the older person and family receive and understand
                                                 èèrelevant and current information concerning their health care/
                                                   needs on a regular basis and are involved in decisions of care.
                                                 èèAppreciates the barriers to communication due for example,
                                                   to culture, a change in sensory or cognitive status and
                                                   employs strategies to overcome these.
                                                 èèRecognises that all behaviour has meaning.
                                                 èèSafeguards and ensures confidentiality, privacy and informed
                                                   consent.
                                                 èèAccommodates and is respectful and sensitive to the older
                                                   person and their family’s cultural and spiritual diversities.
                                                 èèFollowing the death of the older person provides support for
                                                   the family and facilitates transition into bereavement/support
                                                   services if required.
                                                 èèMaintains dignity and privacy following death,
                                                   accommodating and being respectful and sensitive to the
                                                   older person’s wishes and families’ cultural and spiritual
                                                   diversities.

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Nursing and Midwifery Board of Ireland (NMBI)

                 Performance Criteria          Indicators

     3.2         Actively encourages the       èèEncourages and facilitates the older person to express their
                 empowerment and well-being      preferences with regard to personal environment for care and
                 of older people.                the patterning of their day, ensuring flexibility.
                                               èèElicits the views of the older person.
                                               èèEncourages and provides opportunities for the older
                                                 person to exercise their rights and responsibilities, ensuring
                                                 adequate protection for those people who are unable to
                                                 make their own decisions and/or protect themselves.
                                               èèNegotiates with the older person ways of attaining realistic
                                                 levels of independence.

     3.3          Collaborates with all        èèEstablishes relationships with other team members, based on
                 members of the healthcare       understanding and mutual respect.
                 team and documents relevant   èèCollaborates with other healthcare team members in
                 information.                    providing best practice.
                                               èèEstablishes mechanisms for consultation regarding practice
                                                 and referral.
                                               èèMaintains comprehensive, accurate, clear, concise and current
                                                 nursing records within a legal and ethical framework.

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Nursing and Midwifery Board of Ireland (NMBI)

Domain 4: Organisation And Management Of Care

                 Performance Criteria            Indicators

     4.1         Effectively manages nursing     èèContributes to the overall mission and goal of the healthcare
                 care of the older person          facility/service.
                 within the multi-disciplinary   èèCollaborates with other healthcare team members in
                 team                              providing best practice and establishes mechanisms for
                                                   consultation regarding practice and referral.
                                                 èèOrganises the environment in such a way as to be sensitive
                                                   to and respectful of the needs of the older person and their
                                                   family including their cultural/spiritual/religious values and
                                                   traditions.
                                                 èèIdentifies aspects of care important for quality monitoring,
                                                   for example, functional status, skin integrity, nutritional status,
                                                   medication management and safety practices.
                                                 èèUses available resources to systematically evaluate the
                                                   quality, effectiveness and efficiency of care of the older
                                                   person nursing practices, including the relationship between
                                                   outcomes and care interventions.
                                                 èèInitiates measures to improve nursing care based on
                                                   evaluation findings.
                                                 èèImplements written policies and procedures in line with
                                                   national standards addressing environmental and safety
                                                   issues for the older person including the use of restrictions,
                                                   seclusion and elder abuse.
                                                 èèMaintains systems to manage clinical information ensuring
                                                   confidentiality.
                                                 èèFollows and adheres to Hygiene; Health and Safety;
                                                   Infection Prevention and Control standards and guidelines

     4.2         Leads and empowers nursing      èèEnables nursing team to deliver high quality, patient-centred
                 team within their scope of        evidence-based care.
                 practice.

     4.3         Delegates to other nurses       èèIdentifies the most appropriate person to deliver care and
                 and team members activities       gives directions for care activities delegated to other team
                 commensurate with their           members, including support staff within their scope of
                 competence and within their       practice.
                 scope of practice.

     4.4         Facilitates the co-ordination   èèInvolves the older person/family in decision-making in the
                 of care, embracing the            organisation and delivery of their care.
                 older person’s choices and      èèWorks with team members to ensure that care is appropriate,
                 involvement.                      effective, safe and consistent.
                                                 èèCollaborates with healthcare team members in providing
                                                   best practice and establishes mechanisms for consultation
                                                   regarding practice, consultation and referral.
                                                 èèLiaises and works with agencies providing care for the older
                                                   person.

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Domain 5: Personal And Professional Development

                 Performance Criteria            Indicators

     5.1         Acts to enhance the             èèDemonstrates a commitment to ongoing professional
                 personal and professional          education and life-long learning in care of the older person.
                 development of self and         èèRecognises own and others attitudes, values and expectations
                 others.                            about ageing and their impact on nursing care of the older
                                                    person and their family.
                                                 èèDemonstrates clarity of beliefs and values in caring for the
                                                    older person.
                                                 èèContributes to the learning experience of colleagues through
                                                    a supportive and collaborative framework.
                                                 èèParticipates in quality of care and quality of life activities.
                                                 èèUses the outcomes of audit and education initiatives to
                                                    improve nursing care of the older person.
                                                 èèDevelops professional links with others practising in the same
                                                    area of caring for the older person.
                                                 èèDevelops a culture of change to advocate for, and improve,
                                                    care of the older person.
                                                 èèAcknowledges the need for, and practices, self-care.

     5.2         Participates in education and   èèParticipates in and accepts personal responsibility for
                 professional development           ongoing professional development and education on care of
                 programmes in care of the          the older person.
                 older person.                   èèAcknowledges and values the existence and uniqueness of
                                                    a specialised body of knowledge relating to the care of the
                                                    older person.
                                                 èèAssumes responsibility for having current knowledge in care
                                                    of the older person (physical, psychological, cognitive, social
                                                    and spiritual) and shares this knowledge.
                                                 èèPractices and develops professional competence and scope
                                                    of practice on the basis of this specialised knowledge.
                                                 èèCollaborates with other healthcare team members who have
                                                    a higher knowledge in providing best practice and establishes
                                                    mechanisms for consultation regarding practice and referral.

     5.3         Develops and integrates         èèValues and establishes reflective practice as an integral part
                 a framework to reflect on          of nursing care of the older person.
                 practice, implementing          èèDevelops and integrates a framework to reflect on, and
                 evidence-based nursing             explore, nursing practice in care of the older person.
                 practices to improve care of    èèActs to develop an environment of enquiry and change in
                 the older person.                  providing best practice in care of the older person.
                                                 èèObjectively evaluates nursing practice.
                                                 èèIntegrates evidence-based practices to improve nursing care
                                                    of the older person.

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APPENDICES

Appendix 1. Local Policies And Guidelines
To guide nursing practice, local policies, guidelines and education based on national guidelines, evidence-
based and current best practice are required to be developed, implemented and reviewed regularly and
should include among others:

•    Admission/discharge/transfer planning
•    Care of the older person with behaviour that challenges
•    Care of the older person with delirium
•    Care of the older person with dementia
•    Communication (including those with cognitive impairment and/or deficits in hearing or sight)
•    Confidentiality
•    Continence and elimination
•    Continuing professional education
•    Elder abuse
•    End-of-life care
•    Health and safety policies including safe handling/manual handling
•    Hydration
•    Hygiene services and facilities
•    Infection prevention and control
•    Management of falls and fall prevention
•    Medication management, including self-medication
•    Nutrition (including the use of feeding tubes)
•    Oral care
•    Pain management
•    Pronouncement, verification and certification of death
•    Resuscitation
•    Skin Care (including pressure ulcer prevention and wound management)
•    Statement outlining values and objectives of nursing service
•    Use of adaptive equipment
•    Use of restrictions (physical and chemical)
•    Wills

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Appendix 2. Reporting Allegations of Elder Abuse (HSE 2007)
Elder abuse is a single or repeated act, or lack of inappropriate action, occurring within any relationship
where there is an expectation of trust, which causes harm or distress to an older person or violates their
human and civil rights (DoHC 2002).

Categories of Elder Abuse (DoHC 2008)

•    Physical abuse
•    Sexual abuse
•    Psychological abuse
•    Financial or material abuse
•    Neglect and acts of omission
•    Discriminatory abuse.

Nursing staff have a duty of care to intervene in circumstances where an older person is being abused or is
suspected of being abused.

                                              Health Care Worker                      Notify Gardai if
                                               Suspects Abuse                      immediate and serious

       Notify high risk cases                 Notify line manager                     Notify Gardai if
       to general manager/                                                         immediate and serious
           administrator

                           Notify/refer to senior case
                                     worker

                                                  Assessment                      Following meetings may
                                                                                          be held:
                                                                                     • Case discussion
                                                                                     • Case conference
                                                   Care plan                         • Family meeting.

                                                    Review

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Appendix 3. Nursing Assessment
Nursing assessment requires knowledge, linguistically and culturally effective communication skills,
behavioural observation and comprehensive holistic assessment of older people and their environment.
This enables the nurse to make sound clinical judgements and plan appropriate care with older people
and their families. The assessment process may include other healthcare providers and agencies, with
consideration of maintaining confidentiality. An effective nursing assessment is key to establishing a
nursing care plan for the older person and forms the basis for nursing care.

Without ongoing, documented assessment that allows older people to express their values and
wishes, nursing care is fragmented and does not reflect their needs and preferences. Carrying out a
comprehensive assessment takes time and cannot be done in one encounter. Reasons for this include:
the importance of building up rapport and trust, the wealth of information to be gathered and the wish
of the older person to reminisce. The goals of the care plan that evolve from initial and ongoing nursing
assessments focus on enhancing quality of life.

McConnell E.S. (1997) identified the following key aspects of which to be mindful when carrying out
an assessment:

1.   Pacing: in order to obtain an accurate history and measure of the older person’s abilities and needs,
     sufficient time must be allowed for the person to interpret questions and directives, with time allowed
     for rest in between.

2.   Multifaceted problems: each problem/need an older person encounters is likely to have several
     contributory factors which, in turn, influence other aspects of their lives. Therefore, it is important to
     assess a problem/need from each dimension of a person’s life. For example, the impact of urinary
     incontinence may be caused by infection, pharmacological agents used to treat other conditions,
     musculoskeletal problems, neurological dysfunction, access to or distance from toilet, or psychological
     or social factors.

3.   Functional changes: ageing results in many changes in a person’s body and in their functional
     capacity. It is important to assess the impact of these changes; for example, in older people who are
     diabetic and who have had an above-knee amputation. It is insufficient to just note that they have
     had an amputation. It is important to note the person’s ability to perform the functions of moving,
     dressing, bathing and social activities, as well as maintaining observation of circulation to the other
     limb.

Comprehensive assessment is about getting to know the older person, who the person is and is not
confined to a review or checklist of symptoms, problems or systems. Assessment will vary according
to the setting the older person is being cared in and will include but is not limited to the following:

1.   Biographical information including recent significant life events.

2.   Physical health and illness conditions include oral/nutritional/hydration status and those patients
     who have difficulty swallowing; skin condition, pressure area prevention and damage; wound care;
     continence and elimination patterns; pain management.

3.   Sensory includes visual and hearing abilities and limitations, including aids used.

4.   Functional ability includes mobility, strengths and activities.

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5.   Environment with particular reference to the physical, functional, safety (actual and potential),
     cognitive, psychological, social and spiritual needs of the older person.

6.   Cognitive ability includes level of comprehension and understanding.

7.   Psychological and Mental Health includes mood and behaviour patterns; communication patterns;
     individual coping styles; older person’s values, beliefs and perceptions of their quality of life; suicide
     risk, information needs.

8.   Social includes level of personal support required, likes and dislikes, past and current life-style,
     preferences, habits, and patterning of day.

9.   Spiritual/Religious needs as well as religious/faith beliefs includes identifying aspects of meaning
     and worth in person’s life.

10. Difficulties and needs as perceived by older person

11. Family includes family roles and needs including support and education.

12. Elder Abuse actual or suspected incidences.

13. Community and home support services includes the knowledge, skills and resources available and /
    or required to care for the older person at home.

14. Ongoing support/treatments provided by other healthcare professionals.

Assessing the older person’s needs and taking a nursing history is one of the most skilled nursing
functions. Lekan-Rutledge (1998) identified four levels when assessing the older person:

1.   First-level Assessment is the ‘first impression’ phase of the encounter, where the nurse observes the
     older person’s overall appearance and physical status, sensory function, environment and their ability
     to understand and communicate. Key issues and concerns are also elicited.

2.   Second-level Assessment involves the use of screening techniques/tools to detect, for example,
     the ability of the older person to feed or dress themselves. This level also includes screening for risk
     factors, such as pressure ulcers, nutritional status, cognitive status, depression, mobility and falls,
     living alone and caregiver stress.

3.   Third-level Assessment involves using a comprehensive nursing assessment framework to collect
     specific data systematically in the physical, psychological, social and spiritual domains of care.

4.   Fourth-level Assessment is problem-focussed and elicits more detailed, in-depth information
     to rule in or rule out a nursing diagnosis. It also facilitates the nurse in obtaining knowledge and
     understanding of the older person; for example, when doing an in-depth assessment of the
     contributory factors to delirium, urinary incontinence or when assessing pressure area risk or functional
     status.

Using validated assessment tools minimises the conflict that can occur as a result of differing perceptions
(Flacker et al 2001). They also enable other members of the healthcare team to report clinical observations
in a systematic manner and, in effect, give them a voice (Froggatt 2000).

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Cowan, L.S., Hengstberger-Sims, C., Eagar, S.C., Gregory, L., Andrew, S., Rolley, J. (2008) Competency
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Davies E., Higginson, I. (2004) Better Palliative Care for Older People. Denmark. WHO Regional
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Department of Health and Children (2002) Protecting our Future. The Working Group Report on
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Department of Health and Children (2006) Towards 2016: Ten-Year Framework Social Partnership
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Department of Health and Children (2008) Tackling Chronic Disease. A Policy Framework for the
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Fawcett, J. (1984) The metaparadigm of nursing: Present status and future refinements. Image:
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